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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit No. <br /> Telephone: (-209) 466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued � ► S-7 <br /> This . Permit >Ex ires 1 Year From Date Issued <br /> n e <br /> Complete ITriplicati <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install -the work herein described. This application is made in compliance with San <br />.'oaq,,:in County -Ordinance No.- 1862 and the Rules and Regulations of the San Joaquin Local Health <br /> District. <br /> EXACT STREET ADDRESS 02, CITYJTOWN ESC epi <br /> Owner' s Name f - -7 Phone <br /> Address 4,00l City <br /> Contractor' s Name License Phone <br /> yr <br /> IS CERT I FICATE OF WORK11A_N'S COMPENSAT IO"!_ I114SURA11JCE_ON__FI.LE_�W_ITH <br /> TYPE OF WORK (Check) : �NE.Ww-WELL❑ DEEPEN ElRECONDITION ❑ DESTRUCTION❑ � t <br /> WELLtC4L:OR1_NATION Q WELL ABANDONMENT ❑ OTHER❑ <br /> PUMPU NSTALLATION R1PUMP REPAIR UMP REPLACEMENT C) _ k <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES,. - PIT--PRI.VY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE'`pIT: OTHER t <br /> PROPERTY LINE -. PRIVATE DOMESTIC WELL` i .� PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL "� \-_ =..CONSTRUCTION SPECIFICATIONS <br /> Industrial— -.-E*c-.a-v-a t i o n I <br /> Domestic/private ,# Dri l 1_edDia. of Well Casing <br /> Domestic/public Driven ' Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic_ Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed by: <br /> PUMP INSTALLATION: Contractor -7,-AO, .� <br /> Type of Pump H.P. - <br /> PUMP REPLACEMENT: CI State Work Done ' <br /> PUMP REPAIR: ❑State Work, Done_____r __- - - -- -- <br /> DESTRUCTION OF WELL: Well Diameter -,Approximate Depth E <br /> Describe Material ' and Pi^ocedufe <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> with San Joaquin County Ordinances , State Laws , and Rules and Regulations of the San Joaquin Local ! <br /> Health District. Home owner or licensed agent's signature certifies the following: <br /> "I certify that�` in tWi perfdrmance!cf 'the work for which this permit is issued, I shall <br /> not employ any pe.rson ,.in,,such manne.r.as to become subject to Workman's Compensation <br /> laws of California". <br /> I WILL CALL FOR .A GROUI LNSP,,ECTION:\PRIOR;tT.O„ GROUTING ANDA INA INSPECTION. <br /> SIGNED TITLE: ' DATE:���� <br /> (DRAW PLOT PETN ON„REVERSE- SIDE <br /> FOR D PARTMENT U E ONLY' <br /> PHASE Ih ; <br />,APPLICATION ACCEPTED BY ZIDATE <br />,ADDITIONAL COMMENTS : <br /> PHASE II GROUT INSPECTI N ”" PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -- 7 <br /> PH 1a9A Row 19-77 _ _1 /78 2M <br />